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Based on observation and interview, the hospital failed to ensure privacy in care for one patient (#16) in a total inpatient sample of 30. Findings include:

Observation of the 4 East Unit Nursing Station, at 11:40 A.M. on 4/26/10, revealed the following:

Patient #16 came to the 4 East nurses' station counter. One non-sampled patient was also standing at the nurses' station while another non-sampled patient was seated behind Patient #16 on a corridor chair. A Detox Counselor was also seated at an adjacent nurses' station desk. The Patient asked Unit Nurse Manager #5, who was seated at a desk against the nurses' station wall (approximately 15 feet from the nurses' station counter) about the status of the Patient's discharge plan. The Patient and the Unit Manager then continued to discuss the Patient's medical needs and plans for the Patient's significant other who was also a patient in the hospital. At no time during this 3-5 minute discussion did the Unit Manager, or the Detox counselor attempt to take Patient #16 into another location for privacy or suggest that the discussion be held at another time privately, out of the presence of other staff and patients.

Interview with the Unit Nurse Manager #5 on 4/27/10, and with the Hospital's Privacy Officer on 4/28/10, confirmed that staff should have provided the patient with privacy about personal issues and discharge plans.

Based on observation, record review and interview, the Hospital failed to ensure that a Registered Nurse (RN), evaluated the care needs for four patients( #5, #9, #18, and #32), in a total inpatient sample 30, at admission and on an ongoing basis. Findings include:

1. For Patient #5, the RN staff failed to routinely assess the patient for pain.

Patient #5 was admitted on 4/24/2010, with diagnosis of seizure disorder, anxiety, right shoulder pain secondary to dislocation in 1/2010 and alcohol detoxification.

Record review revealed a pain assessment completed by the physician on 4/23/2010, which rated the patient as having 6 to 10 out of 10 right shoulder pain that required medication, hot and cold packs and rest to reduce the pain level to a 3 out of 10. The physician ordered Tylenol 325 milligrams (mgs), two tablets orally, every four hours as needed (PRN) for headaches/pain/aches to be alternated with doses of Aspirin 325 mgs, two tablets orally, every fours PRN.

The nursing care plan, dated 4/24/2010 for pain, had interventions that stated "pain will be assessed to determine need for medication and hot and cold packs will be utilized."

Observation and interview with the patient on 4/27/2010 at 10:30 A.M., revealed the patient had severely limited range of motion in the right shoulder and could not lift his arm away from his side(abduct) more than 45 degrees with normal range being 180 degrees. The patient stated he had constant pain and aching in the shoulder from a dislocation in January. The patient stated "no pain medications had been administered since admission but today the physician said he would order a "numbing patch" to help me with this pain."

Interview with RN #3, on 4/27/2010, at approximately 11:00 A.M., revealed that the patient "never asked for anything." When asked how they (nurses)assess for pain, RN #3, stated, "she asks the patients if they need anything when she does morning rounds. RN #3 stated she did not check routinely during the day, as the patients are expected to come to the desk and ask if they need anything."

2. For Patient #9, the RN failed to assess the patient's skin integrity on admission when the patient reported an open area.

Patient #9 was admitted on 4/23/2010, with diagnoses of immune deficiency disease, Hepatitis C, history of recurrent skin lesion of the thigh and lower back infected with Methicillin Resistant Staphylococcus Aureus (MRSA), and opiate and benzodiazapine withdrawal.

Review of the nursing admission assessment, dated 4/23/2010, completed by RN #6, revealed that the patient reported the presence of a boil that was MRSA negative. There was no evidence of any skin assessment by the RN to validate the presence or absence of the boil. Interview with RN #6, on 4/27/2010 at 3:00 P.M., confirmed she did not perform a skin assessment and only documented what the patient reported. RN #6 stated the patient told her the boil was in the lower back /buttock area located under the area covered by underpants.

According to the Hospital policy for patients with history of multiple drug resistant organism infections (such as MRSA), if the patient had any open areas, contact precautions would be required, while in the hospital.

Interview with the Infection Control Nurse (ICN) on 4/28/2010 at 9:00 A.M., confirmed the patient may have needed contact precautions if the boil was open. At 11:00 A.M., on 4/28/2010, the ICN reported he had checked the patient's skin and it was presently intact.

Interview with the Director of Nursing on 4/28/2010, at 2:00 P.M. confirmed it was the RN's responsibility to do the skin assessment.

3. For Patient #32, the RN failed to evaluate the patient for the risk for dehydration and plan care accordingly.

Patient #32 was admitted 4/21/2010 with diagnoses of binge drinking for one week, hypertension, asthma and depression.

Record review revealed the physician ordered laboratory studies which included a blood urea nitrogen (BUN) and serum creatinine on 4/22/2010. The results of the tests revealed an elevated BUN of 27 (normal 5-25) and an elevated serum creatinine of 1.44 (normal .5 to 1.4). Elevations of BUN and creatinine are potential indicators of dehydration.

Review of nursing and physician progress notes for 4/22 through 4/24/2010 revealed the patient had issues with confusion, impaired memory and loose stools with incontinence. On 4/24/2010, the physician documented that due to increased BUN and creatinine, the patient's renal function would need to be followed. On 4/25/2010, an antidiarrheal medication was ordered and provided once to the patient.

Review of the nursing notes through 4/28/2010, revealed no assessment by the RN related to the patient's potential for dehydration or impaired renal function were performed.

Interview with RN #1, on 4/28/2010 at 11:00 A.M., confirmed that an ongoing assessment of the patient's hydration status should have been completed by the RN and care planned accordingly.



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4. For Patient #18, the RN staff failed to routinely assess the patient for pain.

Patient #18 was admitted on 4/20/2010, with diagnoses of Bipolar Disorder and opioid dependency.

Medical record review on 4/26/2010 at approximately 8:50 A.M., revealed a Nurse Practitioners's Progress Note dated and timed 4/24/10 at 12:10 P.M., which stated "tongue coated ? thrush." There was no further evidence that the patient was assessed or treated for mouth pain and question of a thrush diagnosis.

Observation and interview with the patient, on 4/26/2010 at 9:20 A.M., revealed the patient had complained to Nursing staff about the continued pain and "rash in her mouth," but that no one had followed up with her in determining the cause of the mouth rash and discomfort. The patient opened up her mouth. The patient's tongue appeared coated and the palate of the mouth appeared to be infected. The patient stated she had constant pain, and had not had any nurse or Physician examine or treat her since 4/24/10. The patient indicated a discharge from the hospital was planned for this date-4/26/10.

Interview with RN #5 on 4/26/2010, at approximately 12:00 P.M., acknowledged that neither a Nurse Practitioner, Physician or staff nurse had followed up in assessing and treating Patient #18's mouth discomfort, since 4/24/10. Interview with the patient's Physician at 12:10 P.M. revealed the Physician had not been made aware of the patient's mouth pain until Surveyor inquiry. At 12:43 P.M., the Physician examined the patient just prior to discharge, and determined the resident "had vesicles on the soft palate consistent with a viral illness." No further treatment was recommended by the Physician prior to patient discharge.

Based on observation, record review and patient and staff interviews, the facility failed to develop and keep current a nursing care plan for twelve patients (#1, #2, #3, #4, #5, #6, #9, #10, #13, #32, #33, #34) in a total sample of 34. Findings included:

1. For Patient #1, medical record review, confirmed by interview with Licensed Practical Nurse (LPN) #1 at 2:30 P.M. on 4/26/2010, revealed that the patient had diagnoses of depression, bipolar disorder, gastroesophageal reflux disease (GERD), and relapse. The hospital failed to ensure that care plans were developed with goals and interventions for these issues.

Additionally, review of the nursing admission assessment revealed that the patient had left shoulder and back pain, with a severity score of 8 out of 10. The medical record lacked a care plan with goals and interventions for pain.

2. For Patient #2, medical record review, confirmed by interview with Licensed Practical Nurse (LPN) #1 at 11:30 A.M. on 4/26/2010, revealed that the patient was oxygen dependent with diagnoses of chronic obstructive pulmonary disease (COPD) and recent pneumonia. Although the medical record had a care plan for respiratory insufficiency, the care plan lacked interventions to achieve the goal of "Medically stabilized physical condition." Additionally, the care plan was initiated on 4/15/2010 and had not been updated for approximately 11 days since the patient's admission.

3. For Patient #3, medical record review, confirmed by interview with Licensed Practical Nurse (LPN) #1 at 10:30 A.M. on 4/26/2010, revealed that the patient had liver disease and was depressed. Although the medical record had a care plan for depression, the care plan lacked interventions to achieve the goal of "Reduce/eliminate symptoms of depressed mood." The care plan was initiated on 4/13/2010 and had not been updated for approximately 13 days since the patient's admission.

Additionally, medical record review, confirmed by patient interview at approximately 1:45 P.M. on 4/26/2010, revealed that the patient had liver pain and was still very tired (since admission). The medical record lacked care plans for these issues.

4. For Patient #33, medical record review at 8:30 A.M. on 4/28/2010, revealed that the patient had diagnoses of panic disorder and depression. The medical record lacked care plans for these issues.

Additionally, review of a physician progress note, dated 4/25/2010, revealed that the patient had 1+ edema of both lower extremities. A physician progress note dated 4/26/2010, indicated that the edema had increased to 2+. The medical record lacked a care plan with goals and interventions for fluid retention.

5. For Patient #34, medical record review at 10:00 A.M. on 4/28/2010, revealed that the patient had diagnoses of anxiety disorder, major depression disorder, and history of suicide attempts. The patient had suffered loss of three significant others in the recent past months.

Review of the Suicide Risk Treatment Plan revealed that it was initiated on 4/14/2010. One objective was that "the patient would sign a safety contract." Further medical record review revealed that the contract was signed on admission. However, the care plan was not updated to reflect this. Interview with Registered Nurse (RN) #7 at approximately 10:15 A.M. on 4/28/2010, revealed that the patient's condition had improved and the Suicide Risk Plan was still in effect. However, the care plan had not been updated to reflect changes in the patient's condition.

Review of the Depression Care Plan revealed that it was initiated on 4/14/2010. The care plan lacked interventions to achieve the goal: reduce/eliminate symptoms of depressed mood and had not been updated for approximately 14 days since the patient's admission.

Interventions listed on the care plan included: teach patient about depression; Psychological/psychiatric consults; psychiatric medication; and dual recovery group. The medical record did contain a psychiatric consult, however, the care plan was not updated to indicate if the consult was completed with a resulting plan of care.

Interview with RN #7 indicated the RN was unable to indicate if the patient was attending 1:1 psychological therapy or a dual recovery group. Interviews with RN #1 and Nurse Practitioner (NP) #1 also failed to indicate if the patient was attending dual recovery groups or receiving 1:1 therapy. All three staff said, "they had no idea if the patient attended these therapies or which other patients attended these therapies." RN #1 said, "The psychologists review all patients' records and decide who they will invite to group. They then go to each selected patient and personally invite them to the group. We (staff) are not informed of which patients attend. RN #1 indicated that these therapies were never included in patients' care plans because they never knew who participated in these therapies." RN #7 and NP #1 confirmed RN #1's statements.

Continued medical record review revealed that the patient also lacked a care plan for anxiety disorder. Interview with RN #7 confirmed that the patient should have had a care plan for this problem.



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6. For Patient #4, the Hospital failed to develop a nursing care plan for depression.

Patient #4, admitted on 4/24/2010, had diagnoses of bipolar disorder, anxiety and alcohol and opiate withdrawal.

Review of the intake and nursing admission history revealed the patient gave statements of feeling depressed with a history of depression.

On 4/25/2010, a treatment plan was initiated for bipolar depression. No objectives were established and no interventions with completion dates and staff assignment were established.

Interview with the 2 E Unit Manager on 4/26/2010 at approximately 2:00 P.M., confirmed the care plan was not complete.

7. For Patient #5, the Hospital staff failed to implement the care plan for pain by not assessing the patient or medicating the patient as needed.

Patient #5 was admitted on 4/24/2010 with diagnoses of seizure disorder, anxiety, right shoulder pain secondary to dislocation in 1/2010, and alcohol detoxification.

Record review revealed the physician ordered Tylenol 325 milligrams (mgs) two tablets orally, every four hours as needed (PRN) for headaches/pain/aches to be alternated with doses of Aspirin 325 mgs two tablets orally, every fours PRN.

Review of the Medication Administration Record (MAR) as of 4/26/2010 revealed the patient had received no PRN pain medications.

The nursing care plan, dated 4/24/2010 for pain, had interventions that stated "pain will be assessed to determine need for medication and hot and cold packs will be utilized."

Observation and interview with the patient, on 4/27/2010 at 10:30 A.M., revealed the patient had severe limited range of motion in the right shoulder and could not lift the arm away from the left side(abduct) more than 45 degrees, with normal range being 180 degrees. The patient complained of constant pain and aching in the shoulder from a dislocation in January. The patient stated "no pain medications were received since admission but today the physician said "a numbing patch to help with pain" would be ordered The patient stated that no hot or cold packs were offered for three days since admission.

Interview with RN #3, on 4/27/2010, at approximately 11:00 A.M., revealed that the patient "never asked for anything." When asked how the nurses assess patients for pain, RN #3, stated, "she asks if they need anything when she does morning rounds." RN #3 added "she does not check routinely during the day as the patients are expected to come to the desk and ask if they need anything."

8. For Patient #6, the Hospital staff failed to develop a nursing care plan to address the patient's frequent seizures.

Patient #6, admitted 4/23/2010, for benzodiazepine withdrawal, had diagnoses of chronic lung disease, asthma, depression, Hepatitis C and chronic pain from spondylitis. The patient did not have a history of seizure disorder.

Review of the nursing notes revealed that on 4/24/2010, the patient collapsed in the hallway and had a 2 and one-half minute seizure. The patient became aroused and was escorted back to the bedroom, where prior to being put in bed, dropped to the floor, thrashing both arms and legs for several seconds. The physician was notified and ordered Ativan 3 mgs, intramuscularly (IM) and Phenobarbital 45 mg IM. Padded side rails were put in place.

On 4/25/2010, at 12:45 P.M., nurse's notes indicated another patient called staff as Patient #6 was on the floor. The patient was found on the floor next to the bed, moving all extremities, and was non-responsive. The patient regained consciousness and was put to bed with padded side rails.

At 1:00 P.M., the physician ordered the patient be sent to the emergency room for a seizure evaluation.

On 4/26/2010 at 11:30 A.M., the patient was observed ambulating independently, from the shower room with a portable oxygen tank in place. The patient's bed was noted to have just the left side rail padded and the right side rail down to allow the patient access in and out of bed.

Review of the nursing care plan on 4/27/2010, revealed no plan was developed to address the patient's new onset of seizure activity.

Interview with RN #3, on 4/27/2010 at approximately 12:00 P.M., confirmed that seizure pads were not used during the day unless the patient had a seizure and that the nursing staff had not formulated a care plan to address the seizures other than the placing seizure pads on the side rails..

9. For Patient #9, the Hospital staff failed to develop a nursing care plan to address the patient's high risk for infection.

Patient #9 was admitted on 4/23/2010 with diagnoses of immune deficiency disease, Hepatitis C, History of recurrent skin lesion of the thigh, lower back infected with Methicillin Resistant Staphylococcus Aureus (MRSA), now admitted for opiate and benzodiazapine withdrawal.

Review of the nursing admission assessment, dated 4/23/2010, completed by RN #6, revealed that the patient reported a boil that was MRSA negative. There was no evidence of any skin assessment by the RN to validate the presence or absence of the boil. Interview with RN #6, on 4/27/2010 at 3:00 P.M., confirmed she did not perform a skin assessment and only documented what the patient reported. RN #6 stated the patient told her the boil was in the lower back /buttock area located under the area covered by underpants.

According to the Hospital policy on patients with history of multiple drug resistant organism infections such as MRSA, if the patient had any open areas, the patient would require contact precautions while in the hospital. The policy also stated that education on good personal hygiene, as well as good hand and respiratory hygiene, would be provided verbally and in a written format.

Review of the nursing care plan revealed no problem/ goals/ interventions identified for the potential for skin infection in this high risk individual.

Interview with the RN #3, on 4/27/2010, at 2:00 P.M., confirmed a care plan should have been written to address the potential risk, education needs, and for skin assessment on a more frequent basis.

10. For Patient #32, the RN failed to evaluate the patient for the risk for dehydration and failed to plan care accordingly.

Patient #32, was admitted 4/21/2010 with diagnoses of binge drinking for one week, hypertension, asthma and depression.

Record review revealed the physician ordered laboratory studies that included a blood urea nitrogen (BUN) and serum creatinine on 4/22/2010. The results of the tests revealed an elevated BUN of 27 (normal 5-25) and a elevated serum creatinine 1.44 (normal .5 to 1.4). Elevations of BUN and creatinine are potential indicators of dehydration.

Review of nursing and physician progress notes for 4/22 through 4/24/2010, revealed the patient had issues with confusion, impaired memory and loose stools with incontinence. On 4/24/2010, the physician documented that due to increased BUN and creatinine, the patient's renal function would need to be followed. On 4/25/2010, an anti-diarrheal medication was ordered and provided one time to the patient.

Review of the nursing care plan revealed that no goals/objectives/ interventions related to the patient's potential for dehydration or impaired renal function were developed.

Interview with RN #1, on 4/28/2010 at 11:00 A.M., confirmed that a care plan should have been developed for this problem.



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11. For Patient #13, the facility failed to implement the plan of care/treatment plan relative to a dietary consultation.

Patient #13, with diagnosis of substance abuse, anxiety disorder and depression, was admitted to the Hospital on 4/24/10.

Review of the 4/24/10 Hospital Nutritional Screen on 4/27/10 revealed that Patient #13 was interviewed by the nursing staff, and Patient #13 indicated that they had experienced an unintentional weight loss of 20 lbs. (pounds) in the past two months (based on an actual weight). Further review of the screen revealed that the Dietician was to be notified for a consultation by the nursing staff by flagging the patient's kardex in the diet box section.

During review of the diet box section on the patient's kardex with Licensed Practical Nurse (LPN) #3 on 4/27/10 at 10:15 A.M., she acknowledged there was no indication that a dietary consult was being recommended to the dietician on the kardex (per Hospital protocol), as planned. During further interview with LPN #3, she also acknowledged that the Hospital had no evidence that the dietary consult had been completed since the patient's admission, as planned.

12. For Patient #10, the facility failed to complete the 4/24/10 substance intoxication/withdrawal plan of care/treatment plan relative to identifying which discipline/staff members would be assigned to assist the patient with the treatment interventions and in obtaining the treatment objectives.

Patient #10, with diagnosis of substance abuse, anxiety and depression, was admitted to the Hospital on 4/24/10.

During review of the 4/24/10 substance intoxication/withdrawal plan of care/treatment plan with the 3 East Nurse Manager on 4/26/10 at 4:10 P.M., she acknowledged that the plan of care/treatment plan was incomplete and did not indicate which discipline/staff members were assigned to assist the patient with obtaining the substance intoxication/withdrawal interventions and objectives.

Based on record review and interview, the Hospital failed to ensure that two patients records (#5 and #8), in a total inpatient sample of 30, contained information which accurately described the patient's response to medications and/or accurately described the patient's progress and status. Findings include:

1. For Patient #8, the nursing staff failed to: document which pain medication was administered for two of three doses given; document the patient's response to the pain medication for one of three doses given; and documented the patient's discharge from the hospital indicating that discharge teaching was done at 1:30 P.M., when the patient had not yet left the hospital but remained on the unit past 2:30 P.M.. Additionally, the discharge paperwork was unsigned by the patient.

Patient #8 was admitted on 4/23/2010, for opiate detoxification with diagnoses of osteoarthritis, chronic lung disease and left shoulder pain.

Record review revealed the physician ordered Tylenol 325 mgs two tablets orally, every four hours PRN for headaches/pain/aches to be alternated with doses of Aspirin 325 mgs two tablets orally, every fours PRN.

Review of the Medication Administration Record (MAR) revealed on 4/25/2010 at 2:30 P.M., the patient received doses of Tylenol on 4/25/2010 at 6:30 P.M. and 4/25/2010 at 10:30 P.M., but the type of medicine (Tylenol versus Aspirin) was not documented in the designated space, as required. In addition, on 4/25/2010, no effect of the pain medication was documented in the designated space on the PRN sheet or in the nursing notes, as required.

Record review on 4/27/2010 at 1:55 P.M., revealed a nursing discharge note written at 1:30 P.M., stating "patient given belongings and D/C (discharge) paperwork. Escorted to lobby for transport to be provided by the hospital." Further record review revealed all three copies of the three page discharge paperwork were still on the front on the chart and were unsigned by the patient. Inquiry with staff revealed the patient was still on the unit and not yet discharged, as of 2:00 P.M.

Between 2:00 P.M. and 2:30 P.M., the patient was observed ambulating about the unit, anxious to leave.

Interview with the Director of Nursing on 4/28/2010 at 2:00 P.M. confirmed nursing staff should not be documenting the patient has left before they actually do.

2. For Patient #5, the Hospital staff documented the patient had a Lidoderm patch for pain management when the patient was not ordered to receive one and had not actually had one applied.

Patient #5 was admitted on 4/24/2010 with diagnoses of seizure disorder, anxiety, right shoulder pain secondary to dislocation in 1/2010 and for alcohol detoxification.

Record review revealed the physician ordered Tylenol 325 milligrams (mgs) two tablets orally every four hours, PRN for headaches/pain/aches to be alternated with doses of Aspirin 325 mgs two tablets orally every fours prn.

Review of the Medication Administration Record (MAR) as of 4/26/2010 revealed the patient had received no PRN pain medications.

Observation and interview with the patient on 4/27/2010 at 10:30 A.M., revealed the patient had constant pain and aching in the right shoulder, related to a dislocation that occurred in January 2010. The patient stated he had not received any pain medications since his admission but today the physician told him he would order a "numbing patch" to help him with his pain.

Review of the nursing notes for 4/26/2010 at 1:45 P.M., revealed a note written by RN #3 that stated "patient using Lidoderm patch for right shoulder."

Review of the physician orders and the MAR confirmed the patient did not have a physician's order and did not receive a Lidoderm patch.

Interview with RN #3 on 4/27/2010 at 2:00 P.M., confirmed she wrote the note based on hearing that the physician was going to order a Lidoderm patch in rounds on 4/26/2010. RN #3 confirmed she did not administer the patch or have any knowledge otherwise that the patient had, in fact, received the patch.

Based on observation, documentation review and staff interview, the hospital failed to ensure dishes were properly sanitized to prevent potential food borne illness to patients and staff.

The findings included:

1. Observation of the dishmachine on 4/27/10 at 9:45 A.M., revealed the final rinse water temperature failed to reach the required temperature of 180 degrees Fahrenheit (F), for proper sanitizing. On 5 of 7 observations of the dishmachine, the final rinse water temperature registered from 172 to 178 degrees F.

2. Following these observations, the Food Service Director contacted the Maintenance Department. The Director of Maintenance indicated the dishmachine's final rinse water temperature should reach 180 degrees F. Maintenance staff made adjustments to the dishmachine's "heat booster" at that time.

At 10:55 A.M., following the adjustments, the surveyor observed the dishmachine in operation again. At that time, the final rinse water temperature reached a minimum of 180 degrees F, as required for proper sanitizing.

3. Review of the 4/2/10 preventive maintenance report from the contracted service company indicated the dishmacine was not equipped with a chemical for sanitizing. The report documented a final rinse water temperature of 183 degrees F for hot water sanitizing.

4. Review of the dishmachine temperature log for April 2010, revealed the final rinse water temperatures registered between 168 degrees F. to 176 degrees F on 23 of 27 days and not 180 degrees F, as required for hot water sanitizing.

The hospital failed to ensure the dishmachine operated properly per the manufacturer's and service company guidelines for proper hot water sanitizing of dishware.

Based on medical record review, review of hospital policy, and staff interviews, the hospital failed to identify, at an early stage of hospitalization, all patients who were likely to suffer adverse health consequences upon discharge due to inadequate discharge planning for two of 30 inpatients (#1, #2) reviewed.

Findings included:

1. Review of the discharge planning policy for Identification of High Risk Patients/Discharge Planning, at approximately 1:00 P.M. on 4/28/2010, revealed that physicians were responsible to identify patients who had at high risk discharge needs. The High Risk Discharge Planner was then responsible to review each admission within 72 hours and document all findings in the medical record.

2. For Patient #1, medical record review at 2:30 P.M. on 4/26/2010, revealed that the physician had identified the patient as high risk for discharge planning, related to placement needs after discharge. Continued medical record review, confirmed by interview with Licensed Practical Nurse (LPN) #1, revealed a High Risk Discharge Planner's placement note dated 4/20/2010, approximately six days after the patient's admission. The record lacked any other progress note(s) that indicated the High Risk Discharge Planner had re-evaluated the patient on an ongoing basis, and prior to discharge, based on the individual's status, although required.


3. For Patient #2, medical record review at 11:30 A.M. on 4/26/2010, revealed that Nurse Practitioner #1 had identified the patient as high risk for discharge planning related to multiple medical needs. Further medical record review, confirmed by interview with LPN #1, revealed that the record lacked any progress note(s) that indicated the High Risk Discharge Planner had assessed the patient, had begun discharge planning, or re-evaluated the patient on an ongoing basis, for approximately 11 days since the patient's admission.

4. Interview with the High Risk Discharge Planner on 4/27/2010, at 2:00 P.M. confirmed that she had not initiated discharge planning on the above patients within the 72 hour timeframe, as required by hospital policy. The Discharge Planner said that her responsibilities as the 3 East Unit's Case Manager and Discharge Planner utilized most of her working hours. She said, "I do case management and discharge planning on 3 East first, which takes until about 2:00 P.M. daily, leaving me with 2 hours for discharge planning. Then I go to all the other units for high risk care planning. I am also responsible for hospital utilization review. So I don't always have time to see high risk patients in the required time."